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When heart attack patients are asked what they believe caused their disease and this dramatic change in their life, half of the patients quickly respond. "Stress!" Is this reply a convenient excuse, a fashionable fatalistic attitude to avoid responsibility for one's life-style, or is stress a problem which we as physicians do not recognize as we should? Since these questions raise great doubt, we shall discuss this disputed problem in detail.

A person risks an early heart attack if his personality pattern belongs to Type A and is characterized in the following way: he cannot live without a clock, speaks in a hasty and abrupt manner, is unable to listen, constantly interrupts others, insists on doing several things simultaneously, focuses conversation on himself, constantly attempts to outdo others, cannot enjoy anything without a guilty conscience, clenches his fists, and skims over these lines with great impatience.

These two American physicians studied the behavior pattern of healthy individuals over several long term periods and subsequently differentiated two main types of behavior. They then compared the incidence of heart attack in the two groups, calling the description quoted above 'Type A' and the opposite of this personality pattern 'Type B'. After only a three year observation period, they discovered that the incidence of myocardial infarction was 2.2 times higher among individuals of Type A than among Type B. It must be added, however, that the findings of Meyer-Friedman and Rosenman are questioned in medical circles. Our opinion may be summarized with the following statement: although simplified, a coronary prone pattern (type A) behavior exists to some degree.

Many observers and epidemiologists express the opinion that the primary risk factors such as hypertension, abnormal fat metabolism, and smoking, have a common denominator in secondary risk factors. Thus there is in the view of some psychologists, sociologists, and animal experimentors a certain smoker's personality and a certain hypertensive life-style which leads to an increased activity of the sympathetic nervous system and thus to hypertension. In other words, the secondary risk factor is "stress." But what exactly do we mean by this?

Dr. H. Selye first defined stress as the reaction of an. organism to external influences which provoke it to either fight or flight. Selye differentiates the life-preserving reaction as healthy stress (for example the immediate fight or flight reaction of a cat when it is provoked) from what he calls distress resulting from the impossibility of either fight or flight (as in the case of an in prisoned cat or man). However, this differentiation is not always valid in everyday situations. We therefore propose to make stress a more useful term by redefining it as over-exertion.

Almost half of our patients believed that stress in their occupation or personal life caused the heart attack. The patient apparently refers to over-exertion in his way of life which may have lasted for a long period of time and which resulted in disease when he was unable to resolve the problems. Scientists, in particular those involved in behavior modification and zoology, refer to this way of life as overloaded "role situations," which result for example when the normal social structure is altered. Dr. Lennart Levy in Stockholm has defined the following common stressors or psycho-social factors in over-exertion:

Poor adjustment of people to their environment, for example, discrepancies in occupation and personal life, between ability and capability, needs and possibilities, or expectations and reality.

Over-exertion resulting from conflicting roles, for example, in being both career-oriented and a family person.

Problems due to the lack of life-fulfillment which could sometimes be avoided, but cause crises, often in middle age, when we suddenly question the purpose of our existence.

Frequent role changes, for example, in occupation and place of living. This factor has been studied extensively and it has been shown that persons with greater mobility than others are more prone to heart attacks, although it has been questioned as a real contributing factor.

Changes in social norms, institutions and roles can be expressed in a more common manner as transformations of our values and attitudes in religion, marriage, partnership, authority and emancipation.

This list comprises the factors with which research is concerned, although it must be emphasized that the hypotheses mentioned are disputed by many physicians. It is also hoped that this discussion will enable the reader to evaluate his personal stress situation. Do you consider yourself as belonging to Type A described by Friedman and Rosenman? Are you excessively ambitious? Or can you identify with the following patient? A fifty year old owner of a small tool-making plant (25 employees) has been engaged in competitive sports since his youth, living in accordance with the point system established by the American sports physiologist, Dr.

Cooper. He runs 12Vi miles even on Christmas day and during his convalescence from a heart attack he measures the distance of one mile in order to run this exact distance back and forth at eight minutes per mile. Such exact measurements of time and distance are typical for this kind of person. But why does someone so active in sports sustain a heart attack? The probable answer is that he is excessively ambitious in both sports and his occupation. Nevertheless the fact that he was so active in sports prevented him form a more serious heart attack involving complications. It was only in the course of his convalescence that he realized he was 'programmed wrong' and should not be so extremely serious in all aspects of his life. Since the general interest in all aspects of psycho-social stress is wide-spread, we have described it in detail. An examination of personal stress and risk factors is helpful to each of us.

It follows from the discussion of the risk factors for coronary heart disease which have been established by new studies of epidemiologists, that metabolic as well as environmental factors must be detected and treated in an early stage. Furthermore, it is clear that in the majority of cases no single risk factor, but instead the interplay of various risk factors, causes the heart attack. Therefore all risk factors must be treated simultaneously in a comprehensive manner. Dr. Jahnecke, an experienced specialist of hypertension, draws the following analogy to emphasize the necessity of comprehensive treatment: The elimination of one particular risk factor such as hypertension without concern for other risk factors is of little use. Similarly there is no sense in equipping a car with the newest safety belts but then speeding down the highway at night without lights, with worn-out tires and defective brakes.


Cardio & Blood